JUDE BARBACK considers the research behind an innovative, virtual, dementia-friendly home and talks to architect, Warwick Bell of BKB Team Architects, about applying the research to New Zealand dementia units.

As I ‘walk’ through the rooms of the virtual home online, I am blown away by the number of features that could potentially make life easier for someone with dementia. I am also struck by the sheer simplicity of some of these features. There are clocks with symbols for night or day, shower controls that are easy to use, drawers labelled with text and images, fish tanks to provide an alternative focus to television, and many more.

International research

The virtual home design online guide, launched in March this year, is a Scottish initiative, based at the University of Stirling’s Dementia Services Development Centre (DSDC), created by Edinburgh architects firm Burnett Pollock Associates and funded by the Nominet Trust. By its online nature, it is able to inform people all around the world on how design can help those with dementia.

The designs hinge on the premise that people with dementia need buildings that do not cause them unnecessary disability. In the same way a building should compensate for the needs of someone in a wheelchair with ramps, lifts, and space for turning, a building should compensate for the impairments of someone with dementia in its design.

What makes dementia-friendly design challenging is that no two dementia sufferers are the same, differing in age, type and degree of impairment, attitude, and background. Those with dementia can experience sensory, mobility, or cognitive impairments, and sometimes a combination of these, which can affect functioning, behaviour, independence, and ultimately, quality of life.

In addition to the virtual home, the Stirling DSDC offers pointers to those aiming to create a dementia-friendly environment, stemming from its research. Given the many differences between people with dementia, the suggestion is to design communal areas to cater for the most impaired residents, which means they will be suitable for everyone.

In order to take into account the different interests of residents, the lounge of a dementia unit should ideally make it possible for people to do different activities, whether it be to sit and read, do jigsaws, or watch television, and so on. If people with dementia are going to feel confident in any space, that space has to tell them what is expected of them.

Stirling’s virtual home is, therefore, just one example of how a dementia-friendly environment would look. However, it does present a comprehensive inventory of design features that would aid people, whatever their type and stage of dementia. The virtual home is aimed to keep people safe from falls, give them confidence to use their abilities to the fullest extent, aid their memory in day-to-day living, and reinforce personal identity.

Hovering over each design feature included in the virtual rooms reveals the rationale behind its presence or positioning. It is suggested for the wardrobe, for example, that it should have an open or non-reflective glazed section to allow visibility of clothes. The door should include a free swing-door closer to allow for easy opening. Clicking on the ensuite toilet reveals that it should be positioned so that it can be seen from the bed.

Lighting is a key component, featuring in every room of the virtual home. The Stirling research shows that poor lighting can increase anxiety and may lead to falls if people cannot make sense of what is ahead of them.

Age is a key factor in the deterioration of eyesight. Research shows that by the time people are about 75 years old, they need twice as much light as normal lighting standards recommend in order to see satisfactorily.

Older people with dementia are further disadvantaged as the ability of the brain affected by dementia to process visual signals is greatly diminished. Ideally, care environments should deliver higher light levels than ‘normal’.

Reflection and contrast, as important factors of vision, should be carefully considered. Sudden changes in lighting levels should be avoided, as should glare from lights. Diffuse lighting helps faces seem less aggressive than spotlighting. ‘Domestic’ style lighting creates a homely feel.

Greater contrast, although contested by some, is said to draw attention to something important. The virtual home suggests a coloured and contrasting toilet seat to help with positioning and a contrasting strip along stair rails.

The opposite effect can be achieved by lowering the contrast. Safer floorings can be achieved by keeping to a single colour over different floor finishes, or making changes in the floor colour gradually rather than suddenly. It is the sudden contrast that can make the floor levels look uneven, like a step, and this can cause hesitation and unsteadiness, which can lead to falls. Patterns are best avoided in flooring as they also confuse the eye. Shiny finishes can look unsafe; matte flooring is preferable.

A change in floor colour, appearing as a step, is a common perceptual problem, typical of those experienced by people with Alzheimer’s disease. Disorientation and bewilderment often result from perceptual problems, which are often exacerbated by other sensory impairments. Adjusting to a new space can be difficult for a person with dementia as it relies on memory and learning.

Putting research into practice

The Stirling DSDC is, of course, just one group informing design solutions for the residences of people with dementia. Similar research communities are dotted around the globe.

Warwick Bell, director of Bell Kelly Beaumont (BKB) Team Architects in New Zealand, says that keeping abreast of architectural design in general is being aware of new projects, both nationally and internationally. While the firm prides itself on adhering to current best practice for aged care facilities, Bell says there are few projects and even fewer publications regarding dementia care buildings specifically.

What research and information is available is taken carefully into account. Bell agrees that features highlighted by the Stirling DSDC and others, such as lighting, colour, accessibility, communal areas, orientation, and signage, are all important to consider in the design of a new dementia unit. However, care is taken where there is conflicting evidence about certain features. Bell says contrast is one area that they treat cautiously as it can be both a positive and negative.

Bell agrees that achieving a homely feel to a unit while adhering to security features is a balancing act.

“The décor and fabric of the facility can be made to be homely so it comes down to the entry and exit from the secure area – that has to be discreetly handled and not made to feel as if it is containment.”

In virtually all projects, most features can be accommodated with good component design, regardless of the funds available for the project, says Bell. Internal courtyards may be excluded on a particularly tight budget, as such plans are less efficient per square metre. Sustainable features, which typically come at a higher price, are also more likely to be deleted from plans.

Each project differs according to the operator’s preferences. Bell says the first step is generally to establish a clear brief that captures the operator’s spatial requirements as well as the overall character desired.

“We use our expertise to encourage the brief to reflect what we consider to be best practice. Then we attempt to develop a concept design that achieves the brief. It is important during that process to challenge both our and the operator’s expectations of what the unit could be by thinking ‘outside the square’. Only then can we be sure the most appropriate design for the unit has been established,” says Bell.

Bell believes designs should always be innovative but not at the expense of meeting the brief.

“One should always remember with design for this age group that one needs to create a homely environment in line with the home environments they have been brought up in. Not all have experienced flash city apartments or international-style architecture – probably over 80 per cent of residents are comfortable in their suburban weatherboard house,” says Bell.

BKB also get involved with sourcing materials for their designs. Bell says material and product specification comes from much experience and knowing what works and what does not in aged care facilities.

“We have a philosophy that our clients should not be the first to try a new product unless it is very obviously a good one. Trialling products can often result in remedial issues further on in the life of the facility.”

BKB aim to future-proof their designs.

“Most facilities will have a minimum life of 30 years, which is dealing with at least two generations of occupants, so providing flexibility in use for different care types is most important,” says Bell.

More information about the Dementia Services Development Centre based at University of Stirling can be found at www.dementia.stir.ac.uk

Case study:

Tuarangi rest home and hospital

Tuarangi rest home and hospital, in Ashburton, has re-opened its doors after extensive expansion and redevelopment. Associate Minister of Health Hon Jo Goodhew and Canterbury District Health Board (CDHB) chief executive David Meates officially re-opened the rest home in late April. The new and improved facilities now offer more options for patients requiring dementia care.

Originally built as ‘Tuarangi Old Men’s Home’ in 1902, the rest home previously provided only hospital and specialised psychogeriatric (Dementia /D6) hospital care for the elderly. However, the Twigger Wing, which provides secure hospital-level dementia care, was described by Meates as “less than ideal” and required significant refurbishment to bring it up to standard. CDHB made the decision to demolish and replace the Twigger Wing, deeming this to be the most cost-effective and beneficial option for patients and staff.

The redevelopment project also saw the addition of the new Moule Wing, giving the rest home an additional 10 beds to provide secure rest home-level care for dementia patients. Thanks to the extensive refurbishment and the additional beds of the Moule Wing, Tuarangi rest home has been transformed into a modern 37-bed facility, that, as Meates says, will allow more people to access dementia and hospital-level care in their own community.

The lower level dementia (D3) care now catered for at Tuarangi is certainly a welcome addition for mid-Canterbury.

“The expansion will avoid the need for people with dementia requiring rest home level of care to move away from the district for long-term residential care,” says Meates.

The Havelock Wing, which provides hospital-level rest home care to all other residents has also been refurbished and upgraded.

Construction began in August 2010 and proceeded well, with the Moule Wing occupied in March 2011. However, the Christchurch earthquake in February 2011 brought the project to a halt. The decision was made to postpone the demolishing of the old Twigger Wing in case it was needed to house displaced patients from Christchurch. The extra beds weren’t needed after all, and construction restarted in May 2011. The old Twigger Wing was demolished and a new wing built in its place, reaching completion in mid-December 2011. The more minor refurbishment work was then carried out on the Havelock Wing. The project was finished in March 2012.

The Tuarangi home redevelopment was a collaborative effort, a “true community project,” according to Meates.

“Not only did the Ashburton community identify the need for these upgrades, but they also came up with the nearly $5 million needed for the redevelopment,” says Meates.

The end result is a modern, stylish, and comfortable rest home and hospital, offering high-quality and comprehensive dementia care to the people of Ashburton.

Case study:

St Joseph’s Home of Compassion, Silverstream, Upper Hutt

The Home of Compassion’s new 16-bed dementia care unit has attracted much praise for its design, winning the 2010 NZACA/INsite Excellence in Care Awards and a Resene Colour Award. As a stand-alone unit, it has provided an opportunity to put into practice the most recent advances in stage III dementia care.

The staff at the home, in consultation with the architects, Bell Kelly Beaumont (BKB)(featured above), have strived for an environment that, while contained and secure, has as many familiar home elements as possible. Pitched roofs, familiar window shapes, and the use of a residential gutter profile around the internal courtyard help enhance the concept of residential familiarity. The material selection, including cedar weatherboards, clear-finished plywood, and timber-look vinyl helps provide a feeling of warmth, as well as being robust and suitable for high-wear areas.

Warwick Bell, director of BKB, stresses the importance of creating a homely environment akin to what they have been brought up in.

While it had to be viable, Theresa McGlynn, the home’s manager, says they were keen to achieve a “more homely feel”, and therefore, they opted for 16, rather than 20, beds. These beds are in high demand; some people have been on the waiting list since 2010.

“We certainly don’t have a problem with occupancy,” says McGlynn.

With easy circulation routes, plenty of natural light and ventilation, and good access to contained outdoor spaces, the dementia unit ticks many of the boxes of best practice dementia-friendly design.

Circulation routes have been kept wide and continuous to avoid dead-ends, where residents could become confused. ‘Bus stops’, small seating areas along the way, have been included to allow residents to enjoy a view or an activity. The views over the adjoining St Patrick’s College playing fields, towards the Hutt River, are played to their best advantage from many different points within the facility.

The all-important security aspect has been incorporated unobtrusively. A monitoring system, the latest nurse-call technology, and sensors on the doors and windows all help staff to monitor the comfort and safety of residents. When a resident gets out of bed at night, motion sensors turn the bathroom lights on to remind them of why they woke up, and a further link will alert the staff to where the activity is taking place.

Colours have been used carefully throughout the unit, creating cues for familiarity throughout the building. For example, all bathroom doors are the same colour. The use of earthy colour tones creates a calming environment for residents and ties in with the strong use of natural materials within the project.

Sustainable design has been a major consideration throughout the development of the project. Site planning, material selections, equipment and services have all been aligned with the applicable green rating standards.

Residents and their families are pleased with the new unit.

“It’s a real little community there,” says McGlynn.

“The abundance of natural light and the outlook make the unit a very welcoming environment to live in and visit.”

Staff are thrilled with the end result as well. The rec officers and nursing staff were unanimous in that they wouldn’t change a thing.

It isn’t surprising that staff are pleased – they were included in the early stages of the design process. McGlynn says they had a lot of useful feedback from staff.

“We displayed the plans for the unit in our entrance way, so that families could also see the design and have their say,” she says.

Case study:

Duncan Lodge, Sprott House, Wellington

Sprott House’s new dementia unit, Duncan Lodge, has been described as ‘state of the art’.

Prior to commissioning the unit, the general manager of Sprott House at the time, the architects, Opus Architecture, and a board member went to Australia on a fact-finding mission. The trip proved very beneficial, as they discovered what worked – and what did not – in Australian dementia units. The team also considered extant literature on dementia care to ensure Duncan Lodge would be relevant to the needs of their potential clientele.

This research helped inform decisions on many aspects of the new unit. For instance, black toilet seats were chosen for the unit as these were thought to be better than white seats for people with dementia. After initially intending to include a ‘blokes’ shed’, a common addition in dementia units, they decided not to, after finding that the Australian experience was that these were not used. Residents are actively encouraged to personalise their rooms, all of which have ensuites.

One family member of a resident is appreciative of the approach taken at Duncan Lodge. “The modern fixtures and fittings allow easy cleaning, but it’s nice that the environment is softened by knick knacks etc. and that the Lodge’s rooms can be personalised, allowing individuality while still being safe.”

General manager of Sprott House, Chris Sanders, says Sprott House has actively moved away from a ‘medical’ view of dementia care and is looking more to lifestyle planning to support their residents, using the Spark of Life approach. In keeping with this philosophy, Duncan Lodge is managed by Lisa Cooke, an occupational therapist.

Cooke says her role, as unit manager, is to support staff in the delivery of quality care to residents with dementia, focussing on aspects of the Spark of Life approach. She says they aim to provide person-centred care that promotes choice, independence, and increased self-esteem at every opportunity.

Cooke believes it is essential to have a good working relationship with families in order to offer support when required and to assist in the planning of care for their loved one.

“Our new lifestyle plans have been very successful with families, as they focus on maintaining a resident’s skills and participation in activities of daily living, including personal tasks, domestic tasks, and leisure interests,” says Cooke.

One of the registered nurses at Duncan Lodge says it is easy to build rapport with residents by utilising information from the lifestyle plan that focuses on individual needs. She also stresses the importance of good communication with families to maintain quality of care.

One of the caregivers says that it has been an interesting experience settling into the new dementia unit: “I have got to admit not every day is smooth sailing. We have our bad and sad moments. Now that I’ve settled in this unit, the staff and residents have become one big family.”

By all accounts, residents’ families appear very happy with the care that Cooke and her team are providing for residents.

One resident’s family member says they were attracted to Duncan Lodge because of the commitment to the Spark of Life programme, as it encourages a care programme based on residents’ individual interests, needs, and reactions rather than expecting behaviour to be a certain way and to conform to institutional routines and requirements.

“I greatly appreciate the good care provided for, and respect shown to, my mum by the staff. While for some residents the sense of confinement can’t be avoided completely, the unit’s good level of natural light and garden access hopefully helps. Plus, for those who are walkers, the corridor loop enables uninterrupted roaming.”

Indeed, it is often difficult to achieve homeliness when the security aspect is such an important component of dementia care. However, Sanders agrees the security aspect is not a limiting factor. The unit was built so that ‘dead ends’ were minimised; ‘walkers’ have a roundel around which they can walk – or they can walk in a figure of eight using the pavilion so that they do not necessarily have to tread the same path all the time.

Sprott House is in the process of developing the outside area of the unit into an area that is relevant for residents to enjoy. Part of this plan will involve a sensory garden with flat access, no obstructions, and raised vegetable and flower beds.

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